They were working for the Anglican Health Service in the Highlands of PNG at St Johns Health Centre, Koinambe, which is an Anglican Mission Station. Prior to their arrival, no doctor had ever been placed in the healthcare system in the Jimi, an area with a population of 33,000. Koinambe is in the Lower Jimi region, and serves a population of 11,000. The Jimi region is named after Jim Taylor, whose search for gold, along with the Leahy brothers, led to the discovery of the heavily populated New Guinean Highlands in the 1930s.

During the 5 weeks we spent in Koinambe, Chris and Toni taught us a huge amount! We came away with a practical experience of tropical and developing world medicine (in an isolated mountain community) but in a much broader sense than we’d ever imagined. We learnt the fundamental lesson that healthcare in this setting involves far more than performing traditional doctor roles in a clinical setting. It means approaching the healthcare of the people in a truly holistic way. Basic infrastructure, communications (i.e. a road link or at the very least a flight once a week to the nearest centre), a clean water supply, services such as schools, a bank and trade stores for healthcare staff and teachers coming into the area from larger centres, are all essential to the health of the community. They are necessities that must underpin any scheme to improve the health and well being of a rural community in the developing world.

Modern medicine has little to offer an area that lacks basic infrastructure. Even the most exciting of recent medical breakthroughs (e.g. the treatment of malaria with arthemether derivatives) is useless in fighting the battle against the disease in this isolated population if work is not first done to provide an accessible, well-staffed, well-stocked healthcare facility that has the support of the local people. In addition there is a problem with two antithetical approaches to healthcare strategies in areas like Koinambe. Larger organisations prepare health policies that sound fantastic (a top down approach to problem solving). However, very few of these ideas filter down to the community level. Top down strategies need to be bridged with the actual situations and needs of the communities (a bottom up approach to healthcare).

We were just beginning to feel settled into the routine of the hospital and over our jetlag when we went on patrol. During the colonial period the British and the Australians ran the country on the basis of patrols. The patrol system was put in place because the population was scattered over vast areas and therefore the government, churches and health services established various posts. From these outposts various people would set out on ‘patrol’. With our rucksacks on our back, containing one change of clothes, sunscreen, water, our precious doxycycline antimalarials, and a torch, we set up the mountainside for 5 days patrol. We started with three bearers who carried the vaccines, other medical supplies, and some food. They saved our lives on numerous occasions especially over the tree trunk and bamboo bridges that were strung across the numerous ravines and fast flowing rivers. The first half-hour was straight up hill, in 100% humidity, and slipping on the most slippery mud in the world, we wondered what had we let ourselves in for!

Messages had been sent ahead during the previous few days, letting the villages know that we would be visiting. We stayed with locals, who let us sleep in their bush huts, and gave us kaukau (sweet potato). We also picked up fleas!
The primary aim of patrol was to get vaccines (BCG, Hepatitis B, the Triple Antigen – measles, diphtheria and pertussis – and polio – if there were supplies in stock) to four mountain communities that had no road link. The patrols also allowed us to carry out child health surveillance programmes, antenatal checks as well as treating the general illnesses of sick patients who had managed to walk down to the village clinics from their isolated homes.

Primary care activities take on a new dimension when they are being carried out half way up a mountain in the tropics with no running water, no electricity and no passable road links. Banana leaves were used to examine patients on and tree branches were used to hang weighing scales.

Traditional Medicine and Sanguma
Talking with the locals we discovered that there is a strong tradition of local herbal medicine and a connection between sorcery and illness. Some of the local tropical medicines included:

• Yellow flower – leaf squeezed and juice drunk with water for gonorrhoea
• Creeping plant, with blue flowers, prepared as above as an abortifacient
• Guava leaves – for scabies, diarrhoea and abdominal pain
• Paw paw seeds chewed, 9 on day 1,6 on day 2, and 3 on day 3 for treatment for malaria.
• Hibiscus leaves – makes vagina more slippery – speeds up labour.
• Hot water and tea for measles.

It is of note that when a child dies from malnutrition, it can be accepted resignedly by some families as sanguma – evil spirits. In these circumstances education drives to advise on child nutrition fall on deaf ears because it is believed that there is an external cause of the decline in the child’s state. We experienced the problem of the social implications of sanguma.

An interesting case was Kunda, now 23 months old. She initially presented with severe malnutrition. The health staff came to learn that the locals thought her mother was a witch and felt that this may have contributed to the social factors involved with failure to thrive. The issue was addressed by the local priest. Around the same time Kunda was started on TB treatment, following the protocol of failure to gain weight despite following several nutrition programmes. Now both Kunda and her mother have gained weight. She was a much happier child. When we left she was trying very hard to take her first few steps!

During the 8 months since Chris and Toni’s arrival in Koinambe they have done a huge amount spearheading community projects to boost local well-being. Their philosophy is that to look after the health of people in a community there is a big need to focus on empowering, educating and enthusing the community and really listening to their concerns.

With this approach since their arrival, the airstrip has been cleared and reopened and there is now a scheme for its regular maintenance. The only access to the village at the current time was the airstrip, because the road was ‘bagarup’ following a kilometre landslide. The village trade stores were empty and so the only source of protein was peanuts and, if one were lucky, a bit of pig.

This destination is not for someone who likes the city nightlife. No electricity or hot water make your elective just slightly more challenging. By the end of the 5 weeks you get used to the cockroaches and spiders and the pit toilet! Food was not the highpoint of the trip. Local cuisine does not include the use of any flavouring and boiled kaukau has little taste to speak of. Having said that you get used to it and the passion fruits on patrol were lifesavers! The village was in crisis state with no food supplies and relied purely on their vegetable gardens yet despite this they sent us off with an amazing feast – a community bumkai. Also, it’s worth mentioning that the only way to get around is on foot and so it’s not for those for whom a walk means a 10-minute stroll along the flat!

Koinambe church forms an important central role in the community. Church services were much longer than we had experienced in the UK and we wondered whether church services could become one of the risk factors for DVTs after sitting on a tree trunk 10 inches off the ground for 4 hours! The services were quite amazing, the priest switching between three languages during the sermon (the local dialect (800 of these in PNG), pidgin and English).

We could not have asked for a better elective. We had an amazing time, achieving our original aim to experience medicine in a totally different context but also so much more. The colleagues we worked with could not have been friendlier- they let us be involved in everything. The community too could not have been more welcoming and the scenery was absolutely stunning.